USA SWIMMING 2019 ATHLETE REGISTRATION APPLICATION

LSC: NT
PLEASE PRINT LEGIBLY  COMPLETE ALL INFORMATION:
LAST NAME LEGAL FIRST NAME MIDDLE NAME

PREFERRED NAME DATE OF BIRTH (MO/DAY/YR) SEX (M/F) AGE CLUB CODE NAME OF CLUB YOU REPRESENT
LAC Lakeside Aquatic Club
(Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter “Unattached”
GUARDIAN #1 LAST NAME GUARDIAN #1 FIRST NAME GUARDIAN #2 LAST NAME GUARDIAN #2 FIRST NAME

MAILING ADDRESS

U.S. CITIZEN: YES NO

CITY STATE ZIP CODE
– ARE YOU A MEMBER OF ANOTHER FINA
FEDERATION? ☐ YES ☐ NO
AREA CODE TELEPHONE NO. FAMILY/HOUSEHOLD E-MAIL ADDRESS
IF YES, WHICH FEDERATION:

OPTIONAL MAKE CHECK PAYABLE TO: HAVE YOU REPRESENTED THAT

DISABILITY: RACE AND ETHNICITY (You may FEDERATION AT INTERNATIONAL
A. Legally Blind or Visually Impaired check up to two choices): Lakeside Aquatic Club COMPETITION? ☐ YES ☐ NO
B. Deaf or Hard of Hearing Q. Black or African American
C. Physical Disability such as R. Asian MAIL APPLICATION & PAYMENT TO:
amputation, cerebral palsy, S. White If your athlete is moving from Stroke to 2019 REGISTRATION FEE
dwarfism, spinal injury, T. Hispanic or Latino Competitive, no need to send pmt, your LAC Sept. 1, 2018 through Dec. 31, 2019
mobility impairment U. American Indian & Alaska Native
D. Cognitive Disability such as V. Some Other Race
account will be billed. USA Swimming Fee $60.00
severe learning disorder, W. Native Hawaiian & Other Pacific NEW MEMBERS, include this form with your LSC Fee $20.00
autism Islander Membership Agreement, birth certificate, and TOTAL DUE $80.00
payment for ALL fees. Mail to: LAC | PO Box
HIGH SCHOOL STUDENTS – Year of high school graduation: 270189 | Flower Mound TX | 75027
Check if you would like to learn more about the USA
YEAR LAST REGISTERED: . IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2018, ENTER THAT Swimming Foundation’s initiatives
CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB: . Check if you would like to receive the electronic USA
Swimming Newsletter (must be 13 years of age or older)
SIGN
HERE x ___________________________________________________________________ ____________________
SIGNATURE OF ATHLETE, PARENT OR GUARDIAN DATE REG. DATE/LSC USE ONLY ____________________